Lower Cesarean Delivery Rate Research Articles

Labor induction versus expectant management for postterm pregnancies: a systematic review with meta-analysis.

To compare routine labor induction with expectant management for patients who reach or exceed 41 weeks' gestation. Computerized databases, references in published studies, and textbook chapters in all languages were used to identify randomized controlled trials (RCTs) evaluating induction and expectant management of labor for postterm pregnancies. We identified RCTs that compared induction and expectant management for uncomplicated, singleton, live pregnancies of at least 41 weeks' gestation and evaluated at least one of the following: perinatal mortality, mode of delivery, meconium-stained fluid, meconium aspiration syndrome, meconium below the cords, fetal heart rate (FHR) abnormalities during labor, cesarean deliveries for FHR abnormalities, abnormal Apgar scores, and neonatal intensive care unit (NICU) admissions. The primary outcomes assessed were cesarean delivery rate and perinatal mortality. Sixteen studies met inclusion criteria for this review. For each study with binary outcomes, an odds ratio (OR) with 95% confidence intervals (CIs) was calculated for selected outcomes. Estimates of ORs for dichotomous outcomes were calculated using fixed and random-effects models. Homogeneity was tested across the studies. Compared with women allocated to expectant management, those who underwent labor induction had lower cesarean delivery rates (20.1% versus 22.0%) (OR 0.88; 95% CI 0.78, 0.99). Although subjects whose labor was induced experienced a lower perinatal mortality rate (0.09% versus 0.33%) (OR 0.41; 95% CI 0.14, 1.18), this difference was not statistically significant. Similarly, no significant differences were noted for NICU admission rates, meconium aspiration, meconium below the cords, or abnormal Apgar scores. A policy of labor induction at 41 weeks' gestation for otherwise uncomplicated singleton pregnancies reduces cesarean delivery rates without compromising perinatal outcomes.

Effectiveness of Nurses as Providers of Birth Labor Support in North American Hospitals: A Randomized Controlled Trial

How effective is support by staff nurses specially trained in labor support? An answer to this question is of special importance in view of the marked rise in cesarean delivery rates noted in North America since the 1960s. A Cochrane Review has found that continuous caregiver support during labor makes cesarean delivery less likely. In the present controlled trial, 6915 women with a live singleton fetus or twins, seen at 34 weeks' gestation or later at 13 US and Canadian hospitals, were randomized when in established labor to either usual care or continuous support from a trained nurse. All centers had annual cesarean delivery rates of 15% or higher. In the study group, women received continuous support for at least 80% of the time from randomization to delivery. Well over 90% of women in both groups received appropriate intrapartum nursing care. The median interval from admission to delivery was 8.1 hours and from randomization to delivery, 6.6 hours. Rates of cesarean delivery were nearly identical in the two groups: 12.5% with continuous labor support and 12.6% with usual care. With continuous support, continuous electronic fetal monitoring was somewhat less likely. There were no other significant differences in maternal events or in immediate neonatal outcomes. All infants were born alive; there were three neonatal deaths. Differences in perceived control during childbirth differed very little in the two groups when women were questioned 6 to 8 weeks postpartum, and there was no significant difference in the frequency of breast-feeding. A wish for continuous labor support in future labors was expressed by 63% of women having this type of care and by 47% of control women. Although continuous intrapartum nursing support may have many advantages, it cannot by itself be relied on to lower rates of cesarean delivery or other intrapartum interventions.

Vaginal birth after cesarean in California

OBJECTIVE: To estimate rates at which women were offered and consented to trial of labor in California hospitals with high and low risk-adjusted cesarean delivery rates. METHODS: From 267 nonfederal acute-care hospitals in California that performed more than 678 deliveries in 1992–1993, 51 hospitals were selected in a stratified sample. Hospitals in the sample were categorized as having high, medium, and low risk-adjusted cesarean rates using a logistic regression model based on data from the California Patient Discharge Data System. We reviewed medical records of women with previous cesareans for evidence of counseling regarding trial of labor, other clinical variables, and method of delivery. Differences in proportions between the three groups of hospitals were compared. RESULTS: According to records of 369 women with previous cesareans, after excluding contraindications, 312 were potentially eligible for trial of labor. Hospitals with low risk-adjusted cesarean rates documented counseling women for trial of labor in over 99% of records reviewed, compared with 85% and 79%, respectively, of hospitals with intermediate and high rates ( P < .001). Rates of completed vaginal births after cesarean were 71% in hospitals with low risk-adjusted cesarean rates, compared with 39% and 31% in hospitals with intermediate and high rates ( P < .05). CONCLUSIONS: California hospitals with high cesarean rates in 1992–1993 had markedly higher rates of repeat elective cesarean delivery without evidence of counseling regarding trial of labor. Informed patient choice is a critical element of the decision for trial of labor or elective repeat cesarean, and lack of documented counseling is cause for concern.

Reflections on a Decade of Outcomes Management in Women's Services

Reflections on a Decade of Outcomes Management in Women's Services

The epidemiology of labor induction: Arizona, 1997

Objective: This study was undertaken to describe labor induction risk factors and consequences among women with term singleton gestations with vertex presentation. Study Design: Arizona births in 1997 (N = 65,607) were studied by means of stratified analysis and logistic regression. Results: Labor induction occurred in 20.3% (n = 13,288). Labor induction risk factors were as follows: race or ethnicity (white non-Hispanic 25.3%; Hispanic, 13.9%; foreign-born Hispanic, 10.3%; and US-born Hispanic, 18.5%), education (<12 years, 14.1%; >12 years, 24.6%), payor (private insurance, 24.5%; Medicaid, 16.7%), hospital type (government controlled, 13.7%; investor owned, 30.5%). Race or ethnicity and hospital type remained important determinants of labor induction in the multivariate analysis. Relative risks of cesarean delivery with labor induction were as follows: nulliparous, 1.38; parous with no previous cesarean delivery, 1.00; and parous with previous cesarean delivery, 0.50. Conclusion: Large variations in labor induction were noted across maternal ethnicity and hospital type categories. Labor induction increased cesarean delivery rates among nulliparous women, whereas no increase was seen among parous women with no previous cesarean delivery. Labor induction was used less often among those with previous cesarean delivery; when it was used in this group, however, it was associated with a lower cesarean delivery rate. (Am J Obstet Gynecol 2000;182:1355-62.)

Controversies of Labor Epidural Analgesia

Controversies of Labor Epidural Analgesia

Trial of Labor After Cesarean Delivery

Caughey, A. B.; Shipp, T. D.; Repke, J. T.; Zelop, C.; Cohen, A.; Lieherman, E. Author Information

Reattempting failed external cephalic version under epidural anesthesia

Objectives: We hypothesize that the success rate of external cephalic version may be increased by performing a repeat attempt with the patient under epidural anesthesia. Study Design: One hundred eight women with term singleton pregnancies in breech presentation underwent attempted external version. When external version failed, we offered them the option of a later attempt under epidural anesthesia. All fetuses who remained in breech position were delivered by elective cesarean section. Results: Fifty (60%) of the 83 attempted external versions performed without anesthesia were successful. Seventeen of the 33 women whose versions were unsuccessful underwent elective cesarean delivery, and 16 elected to undergo repeat version attempts under epidural. Nine (56%) of these 16 procedures were successful, and 7 of these 9 women were delivered vaginally. The overall success rate was 71%, similar to the success rate of versions attempted on 25 women under epidural anesthesia. Conclusions: When an attempted external version fails, a repeat attempt under epidural anesthesia will usually be successful, resulting in a lower cesarean delivery rate. (Am J Obstet Gynecol 1998;179:1136-9.)

Trial of labor after cesarean delivery: The effect of previous vaginal delivery

Objective: This study examined the effects of order of previous modes of delivery on the rate of cesarean delivery and duration of a trial of labor among women with a history of 1 previous cesarean delivery and 1 previous vaginal delivery. Study Design: The medical records of 4393 women at our institution who were seen June 1984-July 1996 for a trial of labor after a previous cesarean delivery were abstracted. The 800 women with a history of 1 previous cesarean and 1 previous vaginal delivery were included in this analysis. They were split into 2 groups by obstetric history: (1) 1 cesarean delivery followed by 1 vaginal delivery (vaginal last) and (2) 1 vaginal delivery followed by 1 cesarean delivery (cesarean last). Patient characteristics, durations of labor, and rates of cesarean delivery were compared with χ2 analysis, the Student t test, and the Wilcoxon rank sum test. Possible confounding variables were controlled for with multivariate logistic regression. Results: The rates of cesarean delivery for the vaginal last and cesarean last groups were 7.2% and 14.7%, respectively (P = .002). The median durations of labor for the vaginal last and cesarean last groups were 5.6 and 7.0 hours, respectively (P = .01). The differences in cesarean rates and durations of labor were seen regardless of the indication for the previous cesarean delivery. Conclusions: Among women with 1 previous cesarean and 1 previous vaginal delivery, those whose most recent delivery was vaginal had a lower rate of cesarean delivery and shorter duration of labor than did those whose most recent delivery was cesarean. (Am J Obstet Gynecol 1998;179:938-41.)

Amnioinfusion in labor induction of term pregnancies with premature rupture of the membranes and low amniotic fluid

Objective: To analyze the utility of prophylactic amnioinfusion in term pregnancies with PROM and a low amniotic fluid index during labor induction. Method: Forty-two women with amnioinfusion and 42 in a control group with amniotic fluid index (AFI) below 10 cm when admitted to labor induction were studied. All patients had electronic fetal heart rate and intrauterine pressure continuous monitoring. Amnioinfusion of normal saline (37°C) was realized in the study group, using a continuous perfusion pump at 600 ml/h for 1 h, after which the AFI was again recorded; if this was<15, the perfusion was continued at 180 ml/h until full cervical dilatation was achieved or until uterine baseline activity reached 20 mm Hg. The control group received identical obstetric care except in respect of amnioinfusion. Result: Both groups were similar in age, primiparity, gestational age, initial AFI, interval from rupture of membranes until delivery and length of labor. The amnioinfusion of 600 ml in 1 h significantly increased the AFI (an increase of 7.2±3.9 vs. a decrease of 1.1±1.6, P<0.01). In the amnioinfusion group, there was a significantly lower rate of cesarean deliveries (0 vs. 6, P<0.05) and a better mean umbilical arterial pH at delivery (7.24±0.07 vs. 7.21±0.08, P<0.05). No differences were observed in maternal or neonatal hospitalization days or infectious morbidity. Conclusion: It is concluded that prophylactic amnioinfusion improves neonatal metabolic state when used in labor induction of term pregnancies with PROM and a low amniotic fluid index.

The Effects of Carbohydrate Restriction in Patients With Diet-Controlled Gestational Diabetes

Objective: To determine the effect of carbohydrate restriction on perinatal outcome in patients with diet-controlled gestational diabetes mellitus (GDM).Methods: Women with diet-controlled GDM were divided non-randomly into two groups based on their dietary carbohydrate content: those with low dietary carbohydrate content (below 42%) and those with high dietary carbohydrate content (exceeding 45%). Subjects kept dietary accounts and were followed with daily fasting and postprandial glucose assessments. Subjects also were tested daily for urinary ketones. Glycosylated hemoglobin, mean fasting and postprandial glucose values, incidence of macrosomia and large for gestational age (LGA) infants, cesarean deliveries for cephalopelvic disproportion and macrosomia, and need for insulin therapy were compared between the groups.Results: The two groups were identical in terms of demographic characteristics. Significant reductions in the postprandial glucose values were seen among subjects in the low-carbohydrate group (P < .04). Fewer subjects in the low-carbohydrate group required the addition of insulin for glucose control (P < .047; relative risk [RR] 0.14; 95% confidence interval [CI] 0.02, 1.00). The incidence of LGA infants was significantly lower in the low-carbohydrate group (P < .035; RR 0.22; 95% CI 0.05, 0.91). Subjects in the low carbohydrate group also had a lower rate of cesarean deliveries for cephalopelvic disproportion and macrosomia (P < .037; RR 0.15; 95% CI 0.04, 0.94).Conclusion: Carbohydrate restriction in patients with diet-controlled GDM results in improved glycemic control, less need for insulin therapy, a decrease in the incidence LGA infants, and a decrease in cesarean deliveries for cephalopelvic disproportion and macrosomia.

The Effects of Carbohydrate Restriction in Patients With Diet-Controlled Gestational Diabetes

In Brief Objective To determine the effect of carbohydrate restriction on perinatal outcome in patients with diet-controlled gestational diabetes mellitus (GDM). Methods Women with diet-controlled GDM were divided non-randomly into two groups based on their dietary carbohydrate content: those with low dietary carbohydrate content (below 43%) and those with high dietary carbohydrate content (exceeding 45%). Subjects kept dietary accounts and were followed with daily fasting and postprandial glucose assessments. Subjects also were tested daily for urinary ketones. Glycosylated hemoglobin, mean fasting and postprandial glucose values, incidence of macrosomia and large for gestational age (LGA) infants, cesarean deliveries for cephalopelvic disproportion and macrosomia, and need for insulin therapy were compared between the groups. Results The two groups were identical in terms of demographic characteristics. Significant reductions in the postprandial glucose values were seen among subjects in the low-carbohydrate group (P < .04). Fewer subjects in the low-carbohydrate group required the addition of insulin for glucose control (P < .047; relative risk [RR] 0.14; 95% confidence interval [CI] 0.02, 1.00). The incidence of LGA infants was significantly lower in the low-carbohydrate group (P < 0.35; RR 0.22; 95% CI 0.05. 0.91). Subjects in the low carbohydrate group also had a lower rate of cesarean deliveries for cephalopelvic disproportion and macrosomia (P < .037; RR 0.15; 95% CI 0.04, 0.94). Conclusion Carbohydrate restriction in patients with diet-controlled GDM results in improved glycemic control, less need for insulin therapy, a decrease in the incidence LGA infants, and a decrease in cesarean deliveries for cephalopelvic disproporftion and macrosomia. Carbohydrate restriction in patients with diet-controlled gestational diabetes improves glycemic control and perinatal outcome.

A Clinical Trial of Active Management of Labor

Background Active management of labor is a multifaceted program that, as implemented at the National Maternity Hospital in Dublin, is associated with a lower rate of cesarean delivery than the rate usually found in the United States. We conducted a randomized trial to evaluate the efficacy of this approach in lowering the rate of cesarean section among women delivering their first babies. Methods We randomly assigned 1934 nulliparous women at low risk of complications of pregnancy, before 30 weeks' gestation, to active management of labor or to a usual-care group. The components of active management were customized childbirth classes; strict criteria for the diagnosis of labor; standardized management of labor, including early amniotomy and treatment with high-dose oxytocin; and one-to-one nursing. A low-risk subgroup was defined as including women with full-term, uncomplicated pregnancies who spontaneously went into labor (the protocol-eligible subgroup). Women meeting these criteria who had been randoml...

Amnioinfusion

Amnioinfusion is a commonly practiced technique used for intrapartum improvement of the fetal condition. Room temperature normal saline (0.9 per cent) infused through an intrauterine pressure catheter has been used to alleviate variable decelerations, dilute thick meconium, and improve the intrauterine environment. Randomized studies comparing amnioinfusion to no therapy have shown that amnioinfusion is associated with lower cesarean delivery rates, decreased numbers of operative deliveries, and improved umbilical artery and venous blood gas values. Amnioinfusion also has been suggested as means to instill antibiotics into an infected uterine cavity, or the uterine cavity of a woman with preterm premature rupture of the membranes. Transabdominal amnioinfusion may be used to improved prenatal ultrasound evaluation in pregnancies associated with oligohydramnios. Complications of amnioinfusion include umbilical cord prolapse, uterine overdistention, fetal bradycardia, and one report of possible amniotic fluid embolism. Overall, amnioinfusion seems to be a safe and effective technique to improve the intrauterine milieu.